Skip to main content

Full text of "Head-on collision of Burlington Northern Railroad Company freight trains Extra 6311 West and Extra 6575 East near Westminster, Colorado, August 2, 1985"

See other formats


For Reference 

Do Not Take 

From the Library 







^ 



HE 

1780 
.U58 
86/02 



PB86-916303 







NATIONAL \i;io^^ 

TRANSPORTATION 

SAFETY 

BOARD 

WASHINGTON, D.C. 20594 

RAILROAD ACCIDENT REPORT 



HEAD-ON COLLISION OF 

BURLINGTON NORTHERN 

RAILROAD COMPANY FREIGHT TRAINS 

EXTRA 6311 WEST AND 

EXTRA 6575 EAST 

NEAR WESTMINSTER, COLORADO 

AUGUST 2, 1985 

NTSB/RAR-86/02 



UNITED STATES GOVERNMENT 



TECHNICAL REPORT DOCUMENTATION PAGE 



Report No. 
NTSB/~ " " 



RAR-86/02 



2. Government Accession No. 
PB86-916303 



3. Recipient 's Catalog No. 



Title and Subtitle Railroad Accident Report — 
Head-on Collision of Burlington Northern Railroad 
Company Freight Trains Extra 6311 West and Extra 
fiST.S Kflst nR»r Westminster. Color ado. August 2. 1985 



5. Report Date 
June 20. 1986 



6. Performing Organization 
Code 



7. Autho 



8. Performing Organization 
Report No. 



9. Performir>,g^-^Organization Name and Address 

National Transportation Safety Board 
Bureau of Accident Investigation 
Washington, D.C. 20594 



10. Work Unit No. 
4236-B 



11. Contract or Grant No. 



12. Sponsoring Agency Name and Address 

NATIONAL TRANSPORTATION SAFETY BOARD 
Washington, D. C. 20594 



13. Type of Report and 
Period Covered 

Railroad Accident Report 
August 2, 1985 



1 '♦.Sponsor i ng Agency Code 



IS.Supplementary Notes 



16. Abstract About 7:40 p.m. on August 2, 1985, Burlington Northern Railroad Company 
mixed freight train Extra 6311 West collided head-on with Burlington Northern Railroad 
Company unit gravel train Extra 6575 East at milepost 12.5, near Westminster, Colorado. 
Extra 6311 West was traveling about 52 mph, and Extra 6575 East was traveling about 
48 mph. The trains collided on the single main track during daylight hours in a 2° 41' left 
curve in a westerly direction about 50 feet west of a dual-lane bridge on U. S. Highway 
No. 36. The bridge was destroyed by derailed cars which struck structural support 
members and by fire which erupted following the collision. Three crewmembers of Extra 
6311 West and two crewmembers of Extra 6575 East were killed. The Burlington Northern 
Railroad Company estimated the damage to be about $4 million. 

The National Transportation Safety Board determines that the probable cause 
of the accident was the failure of a crewmember of Extra 6311 West to read the train 
register information correctly at Clear Creek, Colorado, and the failure of the conductor 
to correlate that information with the train orders, which caused Extra 6311 West to 
depart Clear Creek before the arrival of Extra 6575 East, a superior train. Contributing 
to the severity of the accident was the overspeed of Extra 6575 East. 



18. Distribution Statement 
This document is available 
to the public through the 
National Technical Information 

Service, 
Springfield, Virginia 22161 



17. Key Words Non-ABS territory, dark territory, 
train register, train orders, train order 
operator, radio, dispatcher's telephone 
system, toxicology, misinterpretation of 
printed material, fire, bridge destruction, 
sight distance. 



19.Security Classification 
(of this report) 
UNCLASSIFIED 



20.Security Classification 
(of this page) 
UNCLASSIFIED 



21 .No. of Pages 
55 



22. Price 



NTSB Form 1765.2 (Rev. 9/74) 



CONTENTS 

SYNOPSIS 1 

INVESTIGATION 1 

The Accident 1 

Injuries to Persons 6 

Damage 6 

Dispatcher and Crewmember Information 10 

Train Information 11 

Method of Operation 11 

Communications 17 

Meteorological Information 19 

Medical and Pathological Information 19 

Survival Aspects and Emergency Response 21 

Tests and Research 21 

Other Information 22 

ANALYSIS 23 

Non-Critical Elements 28 

Toxicological Tests 30 

Sight Distance • 30 

Survival and Emergency Response 30 

CONCLUSIONS 31 

Findings 31 

Probable Cause 32 

RECOMMENDATIONS 32 

APPENDIXES 35 

Appendix A — Investigation 35 

Appendix B — Personnel Information 36 

Appendix C— Train Orders Extra 6575 East 37 

Appendix D— Train Orders Extra 6311 West 45 

Appendix E — Reverse Side of Clearance Card Used For 

Train Register Information 53 

Appendix F — Track Warrant Control Authority 54 



NATIONAL TRANSPORTATION SAFETY BOARD 
WASHINGTON, D.C. 20594 

RAILROAD ACCIDENT REPORT 

Adopted; June 20, 1986 

HEAD-ON COLLISION OF BURLINGTON NORTHERN 

RAILROAD COMPANY TRAINS EXTRA 6311 WEST 

AND EXTRA 6575 EAST 

NEAR WESTMINSTER, COLORADO, 

AUGUST 2, 1985 

SYNOPSIS 

About 7:40 p.m. on August 2, 1985, Burlington Northern Railroad Company mixed 
freight train Extra 6311 West collided head-on with Burlington Northern Railroad 
Company unit gravel train Extra 6575 East at milepost 12.5, near Westminster, Colorado. 
Extra 6311 West was traveling about 52 mph, and Extra 6575 East was traveling about 
48 mph. The trains collided on the single main track during daylight hours in a 2° 41' left 
curve in a westerly direction about 50 feet west of a dual-lane bridge on U. S. Highway 
No. 36. The bridge was destroyed by derailed ears which struck structural support 
members and by fire which erupted following the collision. Three crewmembers of Extra 
6311 West and two crewmembers of Extra 6575 East were killed. The Burlington Northern 
Railroad Company estimated the damage to be about $4 million. 

The National Transportation Safety Board determines that the probable cause of the 
accident was the failure of a crewmember of Extra 6311 West to read the train register 
information correctly at Clear Creek, Colorado, and the failure of the conductor to 
correlate that information with the train orders, which caused Extra 6311 West to depart 
Clear Creek before the arrival of Extra 6575 East, a superior train. Contributing to the 
severity of the accident was the overspeed of Extra 6575 East. 

INVESTIGATION 

The Accident 

On August 1, 1985, Cheyenne, Wyoming, was subjected to a torrential rain and hail 
storm. As a result of flood conditions at Cheyenne, the Burlington Northern Railroad 
Company (BN) lost most of its telephone and radio communication facilities between the 
Colorado Division, Third Subdivision of the Denver Region and the train dispatcher at 
McCook, Nebraska. Mobile point-to-point radio communications were not affected by the 
flood. 

On August 2, trains on the Third Subdivision that ordinarily would have been 
operated over a longer time span were ready to be moved one behind the other because of 
delays resulting from the flood damage to the communication facilities at Cheyenne and 
because of track work being done on the Third Subdivision between Denver, Colorado, and 
Longmont, Colorado. The traffic movement on the Third Subdivision, which seemed to 
culminate about 3 p.m., and the disrupted communication facilities caused the 3 p.m. to 
11 p.m. train dispatcher at McCook to be busier than usual coordinating an increased 
number of train movements, especially in the Cheyenne area. Normally, six to eight 
trains move over the Third Subdivision during an 8-hour period. 



-2- 



Extra 6575 East. — Extra 6575 East, a unit gravel train 1/ operating between 
Longmont and Clear Creek, Colorado, was scheduled to leave Longmont at 2 p.m. (See 
figure 1.) Because there were no car inspectors located at Longmont, the three-man crew, 
consisting of the engineer, the conductor, and the brakeman, inspected the train and made 
a brake test, as required by Federal regulations. The inspection and brake test were 
completed at 3:15 p.m., and no exceptions were taken to the brakes or the mechanical 
condition of the equipment. 

Following the inspection and brake tests. Extra 6575 East was required to wait at 
Longmont for two westbound trains and for the necessary train orders authorizing the 
gravel train to leave Longmont. At 5:07 p.m., the dispatcher issued train order No. 28 
through the operator at Longmont to the conductor and engineer (C&E) of Extra 6575 East 
(see appendix C) and simultaneously issued the same order to the C&E of Extra 6311 West 
at the 31st Street Yard in Denver. Train order No. 28 stated: 

Extra 6575 East has right over Extra 6311 West Longmont to Clear 
Creek. Extra 6575 East register at Clear Creek on order No. 28 of Aug 
2. Extra 6311 West may check register at Clear Creek against Extra 
6575 East on order No. 28 of Aug 2. 

(signed) JWH 

At 6:13 p.m., the dispatcher issued train order No. 44 through the operator at 
Longmont to the C&E of engine 6575. Order No. 44 authorized engine 6575 to be 
operated as Extra 6575 East from Longmont to Clear Creek and to return to Longmont as 
Extra 6575 West. (See appendix C.) At 6:15 p.m., the dispatcher authorized the operator 
at Longmont to clear 2/ Extra 6575 East with six orders which included train order 
Nos. 28 and 44. (See appendix C.) 

Extra 6575 East departed Longmont at 6:30 p.m. consisting of two locomotive units, 
31 loaded hopper cars, and a caboose, for a total of 4,089 tons. The engineer and the 
brakeman were on the lead locomotive unit, BN 6575, and the conductor was on the 
caboose. 

The conductor of Extra 6575 East testified that the trip between Longmont 
(milepost (MP) 43.6) and MP 12.5 was made without any unusual occurrences. He said that 
the engineer reduced the speed of the train to 10 mph between MP 17 and MP 16.5 in 
compliance with a train order speed restriction and that he took no exceptions to the 
manner in which the engineer handled the train. 

When the train was near Broomfield, Colorado (MP 14), the conductor moved to the 
right side of the cupola in the caboose to observe the train as it moved around a 
right-hand curve near Broomfield. He said that he took no exceptions to the train's 
condition or to the manner in which the engineer was handling the train. He remained on 
the right side of the cupola until the train approached a curve at MP 12.5 so he could 
inspect the train as it moved around the curve. (See figure 2.) The conductor said that as 
the train was moving through the curve, he suddenly saw the headlight of a westbound 
locomotive emerge from under the highway bridge, and knowing the trains were going to 
collide, he braced himself. 



1/ Geographically, trains are operated north and south. Timetable direction is east 
(south) and west (north). Timetable directions will be used in this report. 
2/ A check between the train order operator and the dispatcher to insure that the train 
concerned receives all intended messages and train orders. 



-3- 




o 

■> 

c 





3 

bo 


Rss 


IJH 


i«s^ 




Hxx 




O X X 












a S S 





-4- 




< 



-5- 



Extra 6311 West. — Extra 6311 West was called to depart Denver Yard at 5 p.m. 
However, the train was delayed because of switching cars and conduction of the Federally 
required airbrake tests and inspection. The Federally required brake test and train 
inspection was completed, and no exceptions were taken to the train's mechanical 
condition. Extra 6311 West was further delayed because of the train dispatcher's inability 
to issue the necessary train orders at that time as a result of a heavy work load. 

At 5:05 p.m., the train dispatcher at McCook issued train order No. 28 through the 
train order operator at the BN's 31st Street Yard in Denver to the C&E of Extra 6311 
West at Denver. At 6:24 p.m., the train dispatcher issued train order No. 47 to the C&E 
of engine 6311 through the train order operator at the 31st Street Yard. (See appendix D.) 
Train order No. 47 authorized engine 6311 to be operated as Extra 6311 West between 
Utah Junction, a terminal location in Denver, and Cheyenne. 

At 6:27 p.m., the train dispatcher authorized the train order operator at the 31st 
Street Yard to clear Extra 6311 West with six train orders which included train orders 
Nos. 28 and 47. (See appendix D.) The conductor testified that when he received the 
train orders, he delivered a copy to the engineer. He said that, however, he did not 
discuss the orders with either the engineer or the two brakemen because "they were in a 
hurry to get us out," meaning the yard supervisors wanted Extra 6311 West to leave. 

Extra 6311 West departed the 31st Street Yard at 6:41 p.m. and consisted of three 
locomotive units, 23 loaded and 27 empty cars, and a caboose, for a total load of 
2,862 tons. The engineer, the head brakeman, and the rear brakeman were on the 
locomotive, and the conductor was on the caboose. The rear brakeman had volunteered to 
ride the locomotive to assist the head brakeman with switching work to be done at several 
stations en route to Cheyenne. 

As Extra 6311 West was leaving the yard, the engineer radioed the BN Centralized 
Traffic Control (CTC) operator at the 31st Street Yard and requested that the operator 
ask the Denver, Rio Grande and Western Railroad (D&RGW) dispatcher to display a 
permissive signal at Utah Junction for Extra 6311 West. (The BN and the D&RGW cross 
at grade at Utah Junction and the D&RGW dispatcher controls the home signals.) 3/ The 
conductor broke in at the end of the engineer's transmission to remind the engineer to 
check the train register at Clear Creek; the conductor said that the engineer 
acknowledged the conductor's message. 

Extra 6311 West proceeded 4.5 miles to Clear Creek, where it stopped about 7 p.m. 
with the locomotive standing opposite the train register location so that a crewmember 
could check the train register for the arrival of superior train Extra 6575 East in 
accordance with train order No. 28. Extra 6311 West could not have been operated past 
the train register location because that would have violated the trackage rights given to 
Extra 6575 East by train order No. 28. (See appendix C.) 

Shortly afterward, the conductor received a radio call from an unidentified voice on 
the locomotive. According to a tape monitor recording of the dispatcher's radio circuit 
made through the radio base station at Longmont, the caUer merely said "4:40 
Howard." 4/ After a brief 3- to 4-second delay a response came, "440," and the voice 
trailed off so the balance of the response was unintelligible. The crewmember who 

3/ A roadway signal at the entrance to a route or block to govern trains in entering and 
using that route or block. „^. 

4/ 4:40 refers to the time. Howard was the first name of the conductor of Extra fa^ii 
West. 



-6- 



examined the train register did not sign or initial the pertinent page of the register book. 
(In an early postaceident interview conducted by BN officers, the conductor of Extra 6311 
West said he thought it was the rear brakeman who radioed him the train register 
information, but later he said he was not sure who had called on the radio.) The conductor 
said that the call indicated to him that Extra 6575 East, identified in train order No. 28, 
had arrived at 4:40 p.m and that, based on the information, he authorized the engineer of 
Extra 6311 West to depart Clear Creek and to proceed westward. (See appendix E.) The 
stop at Clear Creek by Extra 6311 West was verified by the conductor and by an 
eyewitness on the property of the Western Paving Construction Company located at Clear 
Creek. 

Extra 6311 West departed Clear Creek about 7:10 p.m., and proceeded westward to 
92nd Street, near MP 10, where it stopped to set off a car. The train departed about 
7:30 p.m., and continued toward Cheyenne. The engineer and the head brakeman were in 
the operating compartment of locomotive unit 6311, and the rear brakeman was in the 
operating compartment of the second locomotive unit, Southern Pacific (SP) 7374. 

About 7:40 p.m., the train emerged from beneath a dual-lane bridge on U.S. 
Highway 36, the Boulder Turnpike, near MP 12.5. Extra 6311 West, which was traveling 
about 52 mph, collided head-on with Extra 6575 East, which was traveling about 48 mph. 
(See figure 3.) 

The three locomotive units of Extra 6311 West and the two locomotive units of 
Extra 6575 East enmeshed and fire ensued from the diesel oil spilled from ruptured fuel 
tanks. Twenty-two cars of Extra 6311 West and 21 cars of Extra 6575 East derailed and 
piled upon and around the locomotives. (See figures 4 and 5.) The engineer and the 
brakeman of Extra 6575 East and the engineer, the head brakeman, and the rear brakeman 
of Extra 6311 West were killed; and the conductor of Extra 6311 West received minor 
injuries. 

The conductor of Extra 6311 West attempted to contact by radio the CTC operator 
at the 31st Street Yard to notify him of the circumstances of the accident, but he was 
unsuccessful because radio channel 1 was being used by BN personnel in the Denver area. 
However, a BN clerk at Golden, Colorado, answered the conductor's emergency radio 
transmission and relayed the collision information to the CTC operator at the 31st Street 
Yard. The CTC operator notified the train dispatcher at McCook and local emergency 
forces. 

Injuries to Persons 

Injuries Extra 6575 East Extra 6311 West Total 

Fatal 2 3 5 

Injured 11 

None 1 1 

Total 3 4 7 

Damage 

The three locomotive units of Extra 6311 West and the two locomotive units of 
Extra 6575 East were destroyed because of structural damage from the collision and the 
ensuing fire. Also 38 freight cars were destroyed. The impact forces of the 
derailing/piling cars against the highway bridge support members and the heat from the 
fire caused the bridge to buckle and distort to partial destruction so that it had to be torn 
out and rebuilt. (See figures 4 and 5.) About 900 feet of the main track were destroyed. 



-7- 




a 



-8- 




Figure 4. — Wreckage looking east. 



-9- 




Figure 5.— Wreckage looking west. 



-10- 

The BN estimated the damage to be: 

Item Damage 

Locomotive Extra $281,121 

6575 East 

Car Equipment 748,000 

Sub-Total $1,029,121 

Locomotive Extra 1 , 094 , 095 

6311 West 

Car Equipment 382,600 

Sub-Total 1,476,695 

Track 24,000 

Bridge 1,500,000 

Sub-Total 1,524,000 

Total $4,029,816 

The $4,029,816 damage value does not include the total cost of the accident. There is no 
allowance for the loss of revenue, the cost of detouring trains, litigation, and other 
associated expenses. 

Dispatcher and Crewmember Information 

The train dispatcher and the crewmembers of each train were qualified for their 
respective positions according to the BN operating rules and requirements. BN employees, 
who formerly were employed by the Colorado and Southern (C&S) Railroad, are given 
physical examinations once every 4 years before age 50 and annually after age 50. (See 
appendix B.) A re-examination on the operating rules is required biennuaUy. At the time 
of the accident, the crew of Extra 6311 West had been on duty 2 hours 40 minutes, and the 
crew of Extra 6575 East had been on duty 5 hours 40 minutes. 

Train Dispatcher. — The dispatcher was well rested when he reported for duty on 
August 2, after having been off duty 16 hours. He stated that he liked his work and that 
he was not concerned about any personal problems that would have distracted him from 
his duties. 

Extra 6311 West. — None of the medical records of the four crewmembers of Extra 
6311 West contained any information concerning uncorrectable difficulties involving 
vision, hearing perception, or other medical factors. 

The engineer had been off duty 13 1/2 hours before reporting for duty at 5 p.m. on 
August 2. Friends of the engineer described him as a conscientious person, a good 
"railroader," and a "super" individual. He was reported to have liked his job and was 
looking forward to retirement. 

The head brakeman had been off duty 13 hours 15 minutes when he reported for duty 
as the relief brakeman at 5 p.m. on August 2. He was considered "very mature, sincere 
and bright" by the BN supervisor who interviewed him and recommended that he be hired. 

The rear brakeman had been off duty 25 hours 15 minutes when he reported for duty 
at 5 p.m. on August 2. He was described as a hard worker who "knew railroading weU." 
One person who saw the rear brakeman on August 2 said that he appeared to be 
"preoccupied and that he was not exhibiting his normal outgoing talkative personality." 



-11- 



The BN crew clerk said that when he called the erewmembers for Extra 6311 West, 
they aU sounded well rested and that no one hesitated to accept the call, except the head 
brakeman who asked to be relieved for the day. The head brakeman's request was denied 
because of the short interval between the time of the call and the time the head 
brakeman was required to report for duty. The head brakeman agreed to accept the 
assignment without further comments The crew clerk later speculated that the head 
brakeman requested to be relieved of the assignment because more severe weather was 
forecast for Cheyenne, which was his home. The crew clerk said that the engineer had 
played golf that day with two other BN employees. 

Extra 6575 East. — The crew of Extra 6575 East reported for duty at Longmont at 
2 p.m. on August 2, after having been off duty 17 hours. The conductor of Extra 6575 
East said that the engineer was "very conscientious" and that both the head brakeman and 
the engineer were in "high spirits." 

Train Information 

Extra 6311 West consisted of 3 locomotive units, 23 loaded and 27 empty freight 
cars, and a caboose, for a total of 2,862 tons. Two of the locomotive units, BN 6311 and 
SP 7374, were type SD-40, built in 1971 and 1980, respectively, by the Electro Motive 
Division (EMD) of General Motors Corporation. The third locomotive unit, BN 6376, was 
type SD-40-2, built in 1974 by the EMD. All three units had six axles, and each was rated 
at 3,000 horsepower. 

Extra 6575 East consisted of two locomotive units, 31 hopper cars which were owned 
by the Western Paving Construction Company, and a caboose, for a total of 4,089 tons. 
BN locomotive units 6575 and 6576 were type SD-45 built by the EMD division of General 
Motors Corporation in 1971. Both locomotive units had six axles and each was rated at 
3,600 horsepower. 

Locomotive units 6311 and 6575 were equipped with Barco speed recorders and two- 
way radios operable on road channel 1 (161.1 mhz) and yard channel 2 (161.16 mhz). 
Neither unit was provided with alerting devices or deadman control facilities. 

The caboose of each train had permanently-mounted radios, and a portable radio 
was assigned to each conductor. 

Method of Operation 

General. — The dispatcher at McCook is assigned to a territory of 284.9 miles, which 
includes the 3rd Subdivision, which extends 237.5 miles from Denver to Wendover; the 
11th Subdivision, which extends 7.7 miles from Broomfield to La Fayette, Colorado; the 
12th Subdivision, which extends 10.3 miles from Longmont to Lyons; the 13th Subdivision, 
which extends 15.3 miles from Prospect Junction, near 31st Street Yard in Denver, to 
Golden, Colorado; and the 14th Subdivision, which extends 14.1 miles from Leadville, 
Colorado, to Climax, Colorado. 

Trains are operated over the Third Subdivision by train orders. Superintendent's 
Bulletins, Timetable, and Special Instructions. The Third Subdivision is not equipped with 
automatic block signals. On August 2, the BN was using the Consolidated Code of 
Operating Rules (Operating Rules) as operating authority; the same rule book is used by 
about 16 other railroad companies. Beginning at 12:01 a.m. on April 27, 1986, the General 
Code of Operating Rules replaced the Consolidated Code of Operating Rules on the entire 
BN system. Also at 12:01 a.m. on April 27, 1986, the TWC system of train operation was 



-12- 



placed into service on a number of subdivisions including the Third Subdivision, 
eliminating the use of train orders and intermediate train registers. The maximum 
authorized speed for freight trains is 49 mph, unless otherwise restricted. 

Although BN locomotives and cabooses are equipped with radios, the BN does not 
require their use in train operations. An attempt is made by BN management to have 
operable radios on trains leaving a terminal, but it is not a requirement. 

The train dispatcher at McCook directs the movement of trains on the Third 
Subdivision by train orders which are issued to the affected train(s) through train order 
operators located in offices at the 31st Street Yard, Longmont, and Fort Collins, 
Colorado, and at Cheyenne, Wheatland, and Wendover, Wyoming. None of the train order 
offices are open 24 hours per day. When the train operator offices are closed, the 
dispatcher may issue train orders by radio to the conductor or engineer of the train. 

Train Orders. — BN operating rule 214 states, in part: 

Train orders must be read promptly upon receipt by those to whom they 
are addressed. Conductors must, when practicable, obtain from 
ei^ineers an understanding of aU train orders before they are acted 
upon. Conductors must, when practicable, show train orders to train- 
men. Engineers must show train orders to members of the crew on the 
engine. All crewmembers are responsible for complying with the 
requirements of train orders and reminding each other of their contents. 

Train Register. — Train register books are provided at initial and final terminals and 
at other locations specified in the timetable. The current timetable indicates that on the 
Third Subdivision, train registers are located at Clear Creek and Broomfield, Colorado, 
and at Platte River, Wheatland, and Moba, Wyoming. At initial and final terminals, 
information, such as the names of the conductor, the engineer, and the brakemen, the 
time they reported for duty, the locomotive unit numbers, the number of loaded and 
empty cars, and the train tonnage must be recorded in the train register. Operating Rule 
83(A) states, in part: 

Unless otherwise provided, conductors of all trains, and engineers of 
trains without conductors, must register their trains on the train register 
at points designated in the timetable. . . . Conductors must fill out train 
register check on the prescribed form and deliver or have it delivered to 
engineer before leaving register station, unless check of trains is 
received by train order or entire movement wiU be within CTC or Rule 
251 territory. 

The BN rules examiner interpreted rule 83(A) to mean that conductors or engineers, when 
applicable, are required to fill out the train register only at initial and final terminals. 
The rule does not designate which crewmember shall check the train register at 
intermediate locations. When the conductor fills out the train register, he must complete 
the train register check form which is printed on the reverse side of the clearance card 
used by train order operators to clear a train with train orders for delivery to the 
engineer. (See appendix E.) 

Any crewmember who has passed the operating rules examination is qualified to 
check a train register at intermediate locations. At intermediate locations, where there 
is no train order operator on duty and when directed to do so by train order, a train 
crewmember must register his train to indicate its status, or he must check the register 



-13- 



to determine the status of another train, i.e., whether an opposing or superior train has 
arrived or left the register location. The erewmembers of Extra 6311 West were not 
required to register the train at Clear Creek, but they had been directed by train order 
No. 28 of August 2 to check the train register. 

Crewmembers who register trains at intermediate locations are required to enter 
the train number and direction; the train order unit (lead locomotive unit number); 
COMPASS train I.D.; 5/ arrival of train on designated track or location; the names of the 
conductor, the engineer, and the brakemen; the number of loaded and empty cars; the 
tonnage; and the caboose number. The operating rules state that the train order number 
and date on which a train is being registered must be inserted in the column headed 
"signals carried." Each day's date must be entered by the crewperson signing the register. 
However, the date is entered at random below the last entry for the previous day or the 
last day the train register was signed, and not in the date blank provided at the top of the 
page. Instructions on procedures and entering train register information are covered in 
employees biennual rules examinations. 

On August 1, Unit 6575 had been used as the train order unit for the gravel train. A 
crewmember of the train had dated and made the required entries in the train register 
according to the operating rules and train order No. 20 dated August 1, 1985. Also, at 
8:30 p.m., a crewmember on Extra 6324 East had signed the train register at Clear Creek 
on train order No. 20 dated August 1, 1985. There were no entries in the train register for 
August 2, 1985. (See figure 6.) 

Operating rule S-83(A) states: 

When a train is required to meet, or wait for, an opposing extra train, or 
when an extra train has been made superior to an opposing train, the 
train register must not be used as evidence of the arrival of such extra 
train, except as provided by Form W train order. Examples (5) or (6). 

Trains must not use the train register as evidence of the departure of an 
extra train, except as provided by train order. 

Train order Form W, Change in Clearance or Register Requirements, states, in part: 

Example (4): Extra 37 West register at 
C on order 
No. _ of (Date). 

Example (5): Extra 38 East may check register at 
C against Extra 37 West on order 
No. of (Date). 



Example (6): No. 2 may check register at C 
against Extra 37 West on order 
No. of (Date). 



5/ COMPASS is an acronym for computer assistance. The ID """""^^j"^^^ -"^^p^.„^ 
management or clerical forces to follow a train's activity. (The COMPASS I.D. lor jixt. 
6311 West was 01-291-02, and for Extra 6575 East was 71822.) 



-14- 




-15- 




3 



-16- 



Examples (4), (5) and (6) must be used when it is desired to permit a train 
to accept the train register as evidence of the arrival of an extra train in 
accordance with rule S-83(A). 

When example (4) is used, number and date of the order must be inserted 
in the column of train register captioned "signals". 

Before the Form W train order was modified by examples 4, 5, and 6, 6/ the 
dispatcher was required to issue a train order to the crew checking the register before the 
crew could accept and act upon the registered time as proof of the arrival or departure 
time of a superior or conflicting train. 

Bulletin No. 122, which was to become effective at 12:01 p.m., Monday, April 22, 
1985, was issued April 17, 1985, to establish Track Warrant Control (TWC) authority for 
the movement of trains on the Third Subdivision. Implementation of the TWC authority 
would have eliminated the need for a train register at Clear Creek and other designated 
locations. In application, the train dispatcher would be required to issue a track warrant 
authorizing a train to proceed from point A to point B only. The train would not be 
allowed to go past point B until the dispatcher issues another track warrant authorizing 
additional movement. (See appendix F.) 

The provision for the establishment of Track Warrant Control authority was included 
in Timetable No. 4, which was to become effective on April 28, 1985. However, because 
of contractual differences with the Brotherhood of Railway, Airline and Steamship Clerks 
union. Bulletin No. 135 dated April 25, 1985 was issued to delete from Timetable No. 4 the 
use of the Track Warrant Control on the Third Subdivision, and the train register system 
was continued in service. The BN is pursuing the implementation of the TWC system for 
operation, and indications are that the difficulties are being worked out. 

Gravel Train Operations. — On April 2, 1985, the BN began operating a seasonal unit 
gravel train over the Colorado Third Subdivision between Longmont, MP 43.6, and and the 
Western Paving Construction Company's facility at Clear Creek, MP 4.5. The gravel train 
has been in operation about 4 years, and it is operated Monday through Friday only from 
about April to October. In accordance with an agreement between the BN and the labor 
unions representing the labor crafts involved, the train is operated with a "short 
crew" i.e., an engineer, a conductor, and a brakeman, who report for duty at 7 a.m. at 
Longmont. 

Cars loaded with gravel are accepted as loaded at a specified weight per car in 
accordance with an agreement between the BN and the Western Paving Construction 
Company. The weight of the gravel load is controlled closely by computerized monitoring 
equipment when the cars are loaded at Lyons, Colorado. The BN makes periodic weight 
checks to monitor the weight of the cars. 

On July 13, 1985, the duty reporting time of the gravel train's crew was changed to 
2 p.m. because of track work that was being done on the Third Subdivision. The later 
operating schedule enabled track forces to work with fewer interruptions, and it caused 
less delay to the gravel train en route to and from Longmont. The trip from Longmont to 
Clear Creek took about 1 hour 40 minutes. 



6/ The change to the Form W train order appears in the Consolidated Code of Operating 
Rules, 1980 edition. 



-17- 



At Clear Creek, the loaded cars are backed onto a wye track 7/ (see figure 1) 
belonging to the Western Paving Construction Company. As the train is backed around 
the wye, the loaded cars are dumped. After the cars have been emptied, which takes 
about 1 hour, the train is returned to Longmont. The crew is on duty between 7 and 
8 hours. 

The conductor and the engineer of the gravel train are provided with a "wheel 
report," which shows the makeup of the train, including the number of loaded and empty 
cars, and the initial, number, weight, origin, and destination of each car. The total train 
weight or load in tons is also provided so that the tons per operative brake can be 
calculated. The conductor or the engineer is responsible for calculating the tons per 
operative brake 8/ using one of the following methods: 

(1) multiply the number of cars times the total car weight and 
compare the result with the actual train tonnage to determine the 
greater value; 

(2) divide the tonnage load of the train by the total number of cars and 
compare the result to determine if the result is greater or less than 
100 tons/operative brake; or 

(3) add two zeros to the total number of cars with operable brakes 
(BN's suggested method) and compare the result with the total 
train tonnage. 

The exact value for Extra 6575 East would be 4,089 Tons/32 cars equals 127.78 Tons 
brake. Following the BN's suggested method, 32 (cars) plus 00 equals 3,200 Tons. (The 
tonnage load was 4,089 tons, which is greater than the trial value.) Timetable and Special 
Instructions No. 4, effective at 12:01 a.m., April 28, 1985, limits the speed of all trains 
operating on the Third Subdivision which exceed a load of 100 tons per operative brake to 
30 mph. 

Train order operators report the train tonnage to the dispatcher. Neither the 
conductor nor the engineer is required to report to the dispatcher if the train is restricted 
to 30 mph because of the 100-ton per operative brake requirement. 

Com munications 

The normal railroad communication facilities available to the train dispatcher at 
McCook consist of a radio, a dispatcher's telephone system, and a commercial Bell 
telephone system. 

Radio System. — The circuit for the radio system is routed from McCook to Denver 
on commercially leased lines. At Denver, the circuit is switched through a bridging 
arrangement to divide the circuit. 9/ Part of the divided radio circuit is routed over the 
Union Pacific Railroad Company (UP) microwave facilities to Cheyenne. At Cheyenne, 
the radio circuit is returned to BN facilities over leased lines and is routed west to 
Wendover and east to Denver. 

7/ A track configured like a "Y" (hence the name wye), which primarily is used to turn 

rail equipment. In most installations, a track spans the legs of the "Y" to allow equipment 

to make a reverse move and to complete the turnaround. 

8/ A value determined from the number of cars with operable brakes and the train load 

Ttons). 

9/ An inductive or electronic arrangement to divide or split a communications circuit so 

ft can be routed in divergent directions. 



-18- 



Radio base stations are located at Longmont and Fort Collins, Colorado, and 

Cheyenne, Horse Creek, Chugwater, and Wheatland, Wyoming. The base stations are 

equipped with 45-watt transmitters. The location and spacing of base stations are 
designed to give overall area coverage and are not determined by distance separation. 

The dispatcher does not monitor radio channel 1 constantly. To contact a train, the 
dispatcher must select the base station nearest the train's location and, through a 
switching arrangement, connect the base station radio facilities to his microphone and 
speaker. Therefore, a crewmember of a train on the Third Subdivision normally cannot 
make a direct radio contact with the dispatcher by a voice annunciation. To talk with the 
dispatcher, a crewmember of a train must contact by radio or telephone the train order 
operator nearest his location, who in turn caUs the dispatcher on the dispatcher's 
telephone. Through the switching networks, the dispatcher selects the base station 
nearest the train and talks to the crewmember through the radio facilities at that station. 
Train-to-train communications are direct point-to-point contacts and the communications 
do not go through the base stations. However, train-to-train order operator or train-to- 
dispatcher communications are routed through the radio base stations. Crew members 
testified that, on occasion, the crews of a westbound train, such as Extra 6311 West, and 
an eastbound train, such as Extra 6575 East, had contacted each other by radio to 
determine the other train's location. 

Railroad personnel who had communicated with the engineer on Extra 6311 West on 
August 2 reported that the radio on locomotive unit 6311 was operating satisfactorily. 
However, on several occasions, including July 31, the engineer of Extra 6575 East had 
reported the radio on locomotive unit 6575 as being "weak." The BN Superintendent of 
Communications stated that, on two of those occasions, BN radio technicians met Extra 
6575 East at the Western Paving Construction Company to check the radio's performance. 
The radio was not replaced on either occasion. The erewmembers who operated Extra 
6575 East between Lyons and Longmont on August 2 did not take exception to the radio's 
performance. 

The radio in the caboose of Extra 6311 West was operable, and there were no 
complaints about its performance. However, the radio in the caboose of Extra 6575 East 
was inoperable because the coax lead to the antenna was uncoupled and the circuit 
breaker, which provided power to the radio set, was "tripped." 

At the time of the accident, the BN was installing a system- wide radio annunciating 
system to provide locomotives with either a touch tone pad, similar to the type used on a 
touch tone dial telephone, or a tone button. In operation, a crewmember on the 
locomotive can call the dispatcher by dialing a prearranged digital code which wiU signal 
the dispatcher, who wiU respond by calling the base station nearest the train. At the time 
of the accident, neither locomotive unit 6311 nor unit 6575 had been equipped with the 
radio annunicating system. 

On August 2 reliable radio communications were not available between mobile units 
on the Third Subdivision and the dispatcher at McCook because of flood damage at 
Cheyenne on August 1. 

BN train crews and the dispatcher testified that radio communications on channel 1 
were not reliable between train crews and the dispatcher in and around the Denver area. 
The dispatcher said that he seldom can use the radio effectively east of Golden or 
Boulder, Colorado, because of heavy use by employees on the yard at Denver. Also, trains 
crews cited dead spots 10/ as a source of trouble in radio communications. 

10 / Locations where radio communications are either unreliable or not possible because 
the radio signals are blocked or diverted. 



-19- 



A BN communication officer stated that work is underway to provide an additional 
radio channel for use in the Denver yard. Also, the Superintendent of Communications 
testified that the BN was attempting to overcome the radio difficulties in and around 
Denver by using a directional antenna and that neither increasing nor decreasing the 
output transmission power would improve the quality of service. 

Telephone System. — The dispatcher's telephone circuit is routed over an open wire 
carrier system 11/ between McCook and Denver. At Denver, access to the dispatcher's 
telephone circuit is provided to the train order and CTC operators before the circuit is 
routed westward on open pole line facilities over the Third Subdivision to about Longmont. 
The telephone circuit for the area between Longmont and Cheyenne is covered by an open 
pole line circuit which originates at Cheyenne. 

The dispatcher's telephone system is available at train order offices and at locations 
along the railroad where they are deemed necessary. At Clear Creek, the dispatcher's 
telephone is located in a T-box 12/ mounted on a telephone pole. (See figure 7.) The 
telephone has no ringing facilities and only the dispatcher can be reached from Clear 
Creek unless a train order operator at one of the train order offices is on the line at the 
time a caller at Clear Creek is using the telephone. The conductor of Extra 6575 East 
testified that, because the dispatcher's telephone at Clear Creek often was inoperative, 
he would have to use a commercial telephone to contact the dispatcher or train order 
operator. On August 2, the dispatcher's telephone system was reliable only between the 
31st Street office and Longmont. 

Meteorolc^cal Information 

At 7:50 p.m. on August 2, 1985, the weather at the Stapleton International Airport 
at Denver, about 20 miles northeast of the accident site, was reported as follows: 
scattered clouds at 5,000 and 9,000 feet with broken ceiling at 20,000 feet; visibility— 20 
miles; temperature — 71° F.; relative humidity — 61 percent; and wind from the southwest 
at 1.5 mph gusting to 5 mph. The visibility by natural light was good. 

Medieal and Toxieologieal Information 

Because of the smoke and heat from the fire following the collision, immediate 
rescue efforts were delayed, and some of the bodies were not removed from the wrecked 
equipment until late afternoon on August 3. A pathologist contracted by Jefferson 
County, Colorado, performed autopsies on the the head-end crewmembers of both trains. 
Toxieologieal tests on tissue, blood, and urine specimens were performed by an 
independent laboratory. AU the tests were negative for alcohol and pharmaceuticals, 
except the tests for the engineer of Extra 6575 East. His blood sample indicated the 
presence of 0.12 percent ethanol alcohol. However, the vitreous humor of all 
crewmembers tested negative. The toxicologists therefore concluded that the alcohol 
detected in the blood of the engineer of Extra 6575 East was due to microbial action 
(putrefaction) and not from alcohol ingestion before the accident. 

An analysis for carboxyhemoglobin (COHb) was negative for all crewmembers 
except the rear brakeman of Extra 6311 West. The COHb analysis for the rear brakeman 
indicated that carbon monoxide concentration was 25 percent saturation by 



11/ An electronic transmission system by which many circuits can be transmitted over a 
single pair of wires or microwave channel by use of separate frequencies, which modulate 
a carrier frequency. 
12/ A box used by railroads to house an outlying, unprotected telephone. 



-20- 




O 



3 



-21- 



spectrophotometric technique. By Co-oximeter, the test indicated a 17 percent 
saturation of carbon monoxide, and 17 percent of methemoglobin. The rear brakeman's 
lungs also contained fluid. 

Survival Aspects and Emei^eney Response 

When the two trains collided, the operating compartments of locomotive units 6575 
and 6311 were structurally destroyed. However, the lead units did not burn during the 
ensuing fire. SP unit 7347 and another unit buried beneath it were engulfed in flames. 
The operating compartment of unit 6575 was not crushed; however, the nose of the 
locomotive and the supporting undercarriage were torn off. 

The operating compartments of units BN 6311 and SP 7374 were crushed upon 
impact and produced an unsurvivable environment. The derailing cars piled upon and 
around the locomotive units causing a jumbled wreckage mass. When the trains collided, 
the lading of gravel from Extra 6575 East and the lading from the head cars of Extra 6311 
West spiUed and added to the wreckage debris. 

Emergency forces from Westminster and other nearby communities, the 
Westminster Police, the Colorado State Police, and the Jefferson County Sheriff's Office 
started arriving at the scene about 20 minutes after the accident. The intense heat and 
the heavy smoke from the burning fuel and equipment delayed search and rescue efforts. 

Tests and Research 

At 7:30 p.m. on August 7, 1985, sight distance tests were made at the accident site. 
BN locomotive units 6339 and 6599, units similar to units 6311 and 6575, were used as test 
trains. The weather conditions were comparable to the conditions on August 2, and 
visibility by natural light was good. The two test trains placed nose-to-nose at the point 
of impact, were oriented with the short hood in the same direction as those of Extras 6311 
West and 6575 East, and were backed away from each other at about the same speed. The 
speed differential between the two closing trains was not considered significant. Sight 
distances were measured at 100-foot intervals. By the use of radar measuring equipment, 
it was determined that the best straight line sight distance available between the two 
trains was 870.74 feet. The actual distance measured along the roadbed with the 
curvature of the track was 876.6 feet. Neither the bridge abutments nor the overhead 
bridge structure was standing when the sight tests were made. Stopping distance tests 
were not made. 

The Barco speed recorders were removed from locomotive units 6311 and 6575 
virtually intact. The glass window in the cover of the recorder from unit 6311 was 
cracked. The spool of recording paper was loose and the glass window in the cover of the 
recorder from unit 6575 was broken. However, both recorders were in a condition that 
would allow a reliable and accurate calibration. The recorders from each unit were tested 
with the following results: 



Unit 
6575 



Wheel Size 




Test Speed 


Recorded Speed 


Deviation 


(inches) 


Gear Teeth 
48 


(m 
20 


iph) 


(n- 


iph 


(mph) 


40 


20 











30 




28 




-1 






40 




38 




-2 






50 




46 




-4 






60 




55 




-5 



-22- 



Wheel Size 




Test Speed 


Recorded Speed 


Deviation 


( inches) 


Gear Teeth 
48 


(mph) 
20 


(mph 


(mph) 


40 


22 


+2 






30 


31 


+1 






40 


40.5 


+0.5 






50 


50 









60 


60 






Unit 
6311 



The overspeed controls were set at 68 mph and 82 mph for units 6311 and 6575, 
respectively. The impact speeds of Extra 6311 West and Extra 6575 East, 52 mph and 
48 mph, respectively, were obtained from the speed tapes with the correction factor 
derived from the test results applied. 

The radios on the locomotives were destroyed and could not be tested after the 
accident. When the radio set from the caboose of Extra 6311 West was connected to the 
antenna and power was applied, it was found to be in an acceptable operating condition. 
The portable radio used by the conductor of Extra 6575 East performed according to the 
manufacturer's specifications. 

About 11:15 p.m. on August 2, a Safety Board investigator and a Federal Railroad 
Administration (ERA) inspector inspected the non-derailed cars in each train. The brakes 
were found applied and the brakeshoe wear and the brake cylinder piston travel were 
found to be within Federally specified tolerances. 

On August 3, an initial terminal airbrake test was conducted on the non-derailed 
cars of each train. BN locomotive unit 2047 was coupled to the remaining 9 cars and 
caboose of Extra 6311 West and the brake system was charged with air for about 
15 minutes. A broken auxiliary reservoir pipe on car WPGX 949914 caused the cars under 
test to have a 6 psi/minute leakage; however, when the auxiliary reservoir pipe was 
repaired, the leakage was 2 psi/minute, which is acceptable (5 psi/minute maximum 
leakage is allowed by Federal regulations). The break in the pipe was determined to 
consist of 70 percent old breakage and 30 percent new breakage. No exceptions were 
taken to the cars' brakes. 

BN locomotive units 8110 and 6749 were coupled to the remaining 27 cars and 
caboose of Extra 6311 West and the brake system was charged. The leakage was 
determined to be 2 psi/minute, and no exceptions were taken to the cars' brakes. 

Other Information 

The train register book at Clear Creek was located on the fireman's side of Extra 
6311 West mounted on the east side of a telephone pole on the south side of the track (by 
timetable direction) in a box about 6" X 24" X 36" with a desk-like sloping lid. (See figure 
7.) The box was locked with a railroad switch lock, and there was no artificial 
illumination or protection from the weather for the box. No trees or obstructions are 
present that would block natural light from falling on the train register book when it is 
placed on the desk-like top of the box in which it is kept for purposes of reading it or 
making an entry. 

The T-box housing the dispatcher's telephone is mounted on the same telephone pole 
supporting the box housing the train register book. The T-Box also is locked with a switch 
lock. (See figure 7.) 



-23- 



ANALYSB 
The Accident 



Operations. — On August 2, 1985, the train dispatcher and the operators at Longmont 
and the 31st Street Yard followed correctly the prescribed operating rules and procedures. 
However, the engineer of Extra 6575 East, unchallenged by the other crewmembers, 
operated the train 18 mph faster than the 30-mph speed limit allowed by the timetable 
special instructions. The crewmembers of Extra 6311 West failed to comply with the 
operating rules on two counts: the train departed Clear Creek without the proper 
authority; and, although not a particularly significant factor in the accident, the engineer 
of that train was operating 3 mph over the authorized 49-mph speed limit. 

Since Extra 6575 East was restricted to 30 mph because the tonnage load exceeded 
the 100 tons per operative brake requirement specified in the timetable special 
instructions, the crewmembers allowed the engineer to operate the train overspeed in 
disregard of the speed restriction. The Safety Board cannot project how the higher speed 
rate might have changed the outcome of the accident. However, Extra 6575 East was 
traveling about 60 percent overspeed (30 mph vs 48 mph). The kinetic energy represented 
by the train at 48 mph was 344,391.2 Ft-Tons, whereas at 30 mph, the kinetic energy was 
134,527.8 Ft-Tons, a difference of 209,863.4 Ft-Tons. If the lower and authorized speed 
had been observed and if the accident could not have been prevented, the lesser energy 
expediture would have increased the chances of the accident being a survivable one. Also, 
at some other point on the railroad, there may have been sufficient time for the engine 
crews to have gotten clear of the train before the trains collided. 

When one of the crewmembers on the locomotive of Extra 6311 West checked the 
train register at Clear Creek, he failed to perceive that the information recorded in the 
train register book was about Extra 6575 East of August 1. As a result of his 
misperception, he provided the other crewmembers with the incorrect information about 
Extra 6575 East. There were no surviving witnesses who could testify that they saw the 
crewmember unlock the register box, remove the train register book, and read the entries. 
The train was standing between the witness in the Western River Paving Construction 
Company so the witness' vision was blocked. However, since the 4:40 p.m. time quoted 
by a crewmember in the radio report to the conductor is a factual entry of record, the 
Safety Board concludes the train register book was removed from its repository and 
viewed by a crewmember. Since it is not known for certain who read the train register, 
the Safety Board could not determine the circumstances surrounding the dissemination of 
incorrect train register information. Although the tape recording of the radio message 
from the crewmember on the locomotive was not of good quality, probably because of the 
distance between Clear Creek and the Longmont radio base station, the reception of the 
message on the caboose by the conductor would have been more easily understood. 

According to the BN rules examiner's interpretation of rule 83(A), the conductor of 
Extra 6311 West was not required personally to sign or examine the Clear Creek train 
register because it was considered an intermediate terminal. Therefore, because they 
were all qualified on the book of operating rules, it was proper and within the scope of the 
operating rules for any one of the three crewmembers on the locomotive to check the 
train register. The locomotive of Extra 6311 West could not have been operated past the 
location of the train register before stopping because the train would have been west of 
Clear Creek and in violation of train order No. 28, which gave Extra 6575.East right over 
Extra 6311 West between Longmont and Clear Creek. Extra 6575 East was authorized to 



-24- 



come to Clear Creek to sign the train register. Therefore, if the conductor of Extra 6311 
West had been required or had elected to check the train register, he would have had to 
walk about one-half mile from the caboose to the train register, opposite the locomotive. 

Generally, the gravel train arrived at Clear Creek earlier than it would have on 
August 2. Therefore, the information that Extra 6575 East had arrived at Clear Creek at 
4:40 p.m. on August 2 was probably not surprising to those crewmembers who had not read 
the train register. Between 4:40 p.m. and 7:10 p.m., the crew of Extra 6575 East would 
have had ample time to have proceeded from Longmont to Clear Creek, dumped the train 
load of gravel, and departed Clear Creek for the return trip to Longmont. The crew of 
Extra 6311 West had a copy of train order No. 28 and they knew Extra 6575 West could 
return to Longmont ahead of Extra 6311 West. 

However, if the crew of Extra 6311 West had been more alert, they should have 
noticed that train order No. 28 was not issued until 5:07 p.m. Since the crewmembers of 
Extra 6311 West were experienced on the Third Subdivision, they should have recognized 
that, based on the running time of about 1 hour 40 minutes for Extra 6575 East to run 
from Longmont to Clear Creek, and the time that train order No. 28 was issued. Extra 
6575 East could not have arrived at Clear Creek before 6:45 p.m. Further, if the crew of 
Extra 6311 West had allowed Extra 6575 East an hour to dump the gravel, the task would 
not have been completed until 7:45 p.m. If this logic had been developed, the crew of 
Extra 6311 West should have questioned why Extra 6575 East was not stiU in the wye 
track at Clear Creek. Even if the crewmembers of Extra 6311 West had not known the 
actual running and unloading time required by Extra 6575 East from Longmont to Clear 
Creek, the fact that train order No. 28 was not issued until 5:07 p.m. should have alerted 
the crew of Extra 6311 West that Extra 6575 East could not have registered at Clear 
Creek at 4:40 p.m., which was before the train order was issued. 

The crewmembers were experienced in train orders and the train register method of 
train operations. The ambient natural light was bright enough so that even without 
artificial illumination, no problem should have been experienced in clearly seeing the well 
defined, legible, and correctly inserted entries for August 1 in the train register. All of 
the crewmembers were reported to be physically alert. There were no known medical 
disorders, visual difficulties, or other problems that would have caused any one of them to 
make such an error. The only crewmember whose behavioral pattern appeared to be a 
little different that day was the rear brakeman, and it is not known whether or not he 
read the train register. Therefore, the Safety Board could not determine the reason the 
information contained in the train register at Clear Creek concerning the registry of 
Extra 6575 East on August 1 was perceived erroneously and relayed to the other 
crewmembers as the status for Extra 6575 East on August 2. 

When the Form W train order was modified as a revision of the Consolidated Code of 
Operating Rules by participating railroads, the required contact with the dispatcher was 
eliminated since the train order authority to accept the train register information was not 
needed. As a result, a positive check for the arrival of a conflicting train also was lost. 
Rule S-83(A) and example 5 of the rule gave the crew of Extra 6311 West the authority to 
use the train register information as evidence of Extra 6575 East's arrival at Clear Creek. 
Therefore, since there was no rule requiring the crew of Extra 6311 West to check with 
the dispatcher or one of the train order operators on either side of Clear Creek to 
determine the location of Extra 6575 East, no attempt was made to contact any of these 
or the train. Moreover, since the lead locomotive unit for Extra 6575 East on August 2 
was the same lead unit that had been used on the gravel train on August 1, a casual glance 
probably would not have caused anyone reading the register to detect any difference in 
the date of a day's separation. Train order number 20 dated August 1, on which Extra 



-25- 



6575 East signed the register at Clear Creek on August 1, was properly recorded in the 
train register book in the "signals carried" column. The train order was numbered in the 
same tens series as number 28 issued on August 2. However, the entry in the train 
register of a train arriving at 8:30 p.m., a time not yet occurring on August 2, should have 
caused the reader to question his identifying the gravel train's arrival at 4:40 p.m. 

Under the circumstances, such similarities could have been conducive to misreading 
the train register if the person reading the register was not concentrating on his task. 
The BN does not require crewmembers who check the train register to make the check 
with the effective train order in hand, so that a comparison can be made between the 
train order and the entry in the train register. However, during the Safety Board's 
deposition proceeding, some crewmembers testified that this procedure voluntarily was 
followed on occasions. 

The conductor said that on August 2, he did not discuss the train orders with the 
engineer of Extra 6311 West because he was being hurried by yard personnel to move the 
train out of the yard. However, since rule 214 states that, "when practicable" the 
conductor and engineer must have an understanding of train orders addressed to them, 
which would be confirmed by a discussion, the conductor's not doing so cannot be termed a 
rules violation. Under the pressure exerted upon him to leave the yard, the conductor 
could have decided that in this instance complying with that part of rule 214 was not 
practicable. Also rule 214 states that all crewmembers are responsible for complying 
with the requirements of train orders. The crewmembers fulfilled the requirement of the 
train order by checking the register at Clear Creek, and even though the information or 
the lack of recorded information for August 2 was correct, the register was interpreted 
erroneously and provoked the wrong action. In all probability, for crewmembers, an 
understanding of the train order is the understanding of the requirements of the order. 
They may check the order number against the clearance card, the date, and perhaps, the 
completion time. The BN should insure that train crews compare and discuss train orders 
with other relevant times and dates. Had such a discussion of the train orders and 
relevant times occurred between the crewmembers of Extra 6311 West, this accident 
might have been prevented. 

Operational Alternatives and Procedures. — At the time of the accident, the BN did 
not provide the train crew with any alternative as a backup for verifying the train register 
information, except the Form W train order. The Form W train order permitted the train 
crew of Extra 6311 West to use the train register information as evidence that Extra 6575 
East had arrived, but there was no requirement that any other action be taken to verify 
the information shown in the train register. 

Nevertheless, there were available options. The crew of Extra 6311 West could have 
contacted by radio the CTC or train order operators at the 31st Street Yard or the train 
order operator at Longmont to determine the location or status of Extra 6575 East, or the 
crew could have contacted by radio the crew of Extra 6575 East. Any one of the 
crewmembers on the locomotive of Extra 6311 West could have caUed the dispatcher 
using the telephone located in the T-box at Clear Creek. During the deposition 
proceedings, crewmembers testified that on occasion, under circumstances similar to 
those of the day of the accident, the crews of the two trains had contacted each other by 
radio to determine the other's location. None of these efforts are required by the BN 
operating rules or procedures and none were done on the day of the accident. 

At least two options were available to the dispatcher on August 2. First, he could 
have held Extra 6311 West at Utah Junction until Extra 6575 East arrived at Clear Creek 
or as a minimum, until Extra 6575 East's running time from Longmont had expired. If 



-26- 



Extra 6311 West had arrived at Clear Creek before Extra 6575 East (as it did), then Extra 
6311 West would have had to make a reverse move across the D&RGW crossing at Utah 
Junction so that Extra 6575 East could gain access to the Western Paving Construction 
Company's wye track. Secondly, the dispatcher could have given the two trains a train 
order to meet at Broom field, or another suitable location. The dispatcher said he did not 
provide a meet between the two trains at Broomfield because he did not know the time 
Extra 6311 West would leave the Denver yard. The most efficient and best move would 
have been for the train dispatcher to have held Extra 6311 West at Utah Junction until 
Extra 6575 East arrived at Clear Creek. Although the movement of Extra 6311 West did 
not become the responsibility of the train dispatcher until the train left Utah Junction, 
the dispatcher's permission should have been obtained before Extra 6311 West entered 
onto the main track under his control. 

Responsibility for the Safety of the Train. — The Safety Board has investigated 
several accidents in which it has taken the position that the conductor should be in a 
position on the train to immediately know current operating conditions. 13/ Based on 
more than 30 major railroad accidents which involved the issue of joint responsibility 
assigned by the operating rules to the conductor and engineer for the safety of the train, 
the Safety Board recommended on May 16, 1985, that the ERA: 

Require that there be at least two crewmembers on locomotives of 
through freight trains who are qualified to operate the locomotive, that 
one of these two persons have total responsibility for the train and aU 
employees thereon, and that the second person serve as the assistant to 
the person in charge. (Class II, Priority Action) (R-85-51) 

A similar Recommendation, R-85-52, was issued to the Association of American 
Railroads (AAR), the United Transportation Union, and the Brotherhood of Locomotive 
Engineers. 

At this time, neither the FRA nor the United Transportation Union has responded to 
the Safety Board's recommendations. The AAR has objected to the intent of the 
recommendation; the Board, however, in further dialogue with the AAR has urged the 
AAR to reconsider the safety benefits implicit in the recommendation. The Brotherhood 
of Locomotive Engineers agrees with the Board's recommendation and is following up with 
the FRA and the industry, urging implementation of this concept. The Safety Board 
believes that if the conductor had been riding on the locomotive when Extra 6311 West 
arrived at Clear Creek, he could have read the train register, even though BN's 
interpretation of rule 83(A) does not require it, and the accident might have been 
prevented. 

During the course of many accident investigations, the Safety Board has heard 
statements from railroad supervisors that if the rules were obeyed, accidents would not 
happen. This logic cannot be refuted so long as the rules are adequate. However, in many 
instances, railroad operating officers wiU not provide backup measures for safety 
assurance in case a rule is willfully or unintentionally broken. The Safety Board believes 



13/ Railroad Accident Report— "Rear End Collision of Two Burlington Northern Freight 
Trains at Sheridan, Wyoming, March 28, 1971" (NTSB-RAR-72-4); Railroad Accident 
Report — "Penn Central Transportation Company Train Collisions, Leetonia, Ohio, June 6, 
1975" (NTSB-RAR-76-2); Railroad Accident Report— "Rear End CoUision of Two Seaboard 
System Railroad Freight Trains at SuUivan, Indiana, September 14, 1983" 
(NTSB/RAR-84/2); and Railroad Accident Report— "Head-On CoUision of Two Burlington 
Northern Freight Trains at Motley, Minnesota, June 14, 1984" (NTSB-RAR-85-06). 



-27- 



that if the railroad operating officers would provide safety backup procedures to 
safeguard train operations, many accidents would be prevented. Historically, railroad 
operating officers have been reluctant to provide backup procedures in the event of a 
rule's violation. Redundant safety procedures are essential in all transportation 
operations to ensure the highest levels of safety. 

The Train Register. — BN supervisors assured Safety Board investigators that all 
necessary guidance for using the train register was covered in the biennial rules 
examinations. However, since all of the information provided for by column headings on 
the train register is not required at aU register locations, the Safety Board believes the 
train register sheet could be simplified at intermediate locations. The Safety Board 
understands the problem of adapting the train register book for each location since it is 
used in various locations on the BN system. However, the August 2 accident has pointed 
out the need for instituting a procedure that wiU reduce the possibility of a train 
erewmember's misreading train register information. At the time of the accident, BN 
operating officers stated that plans were being made for the Track Warrant Control 
system to supplant the train register system in the very near future. Since April 27, 1986, 
when the BN replaced the Consolidated Code of Operating Rules with the Ger.eral Code of 
Operating Rules as the BN's operating authority, and placed the TWC system of operation 
into service on a number of subdivisions including the Third Subdivision, train orders and 
intermediate train registers have been discontinued at these locations. As of May 13, 

1986, the BN had placed the TWC system of train operation into service on 37 Subdivisions 
of the system. By the end of 1986, the BN expects to be using the TWC system on 90 
Subdivisions and it plans to have the entire system operating with TWCs by the end of 

1987. However, as long as the train register system is being used on the BN system, a 
backup system should be implemented to provide the safest operation possible. 

The Track Warrant Control System. — The TWC system seemingly would provide a 
more positive control over train movements than the train register or train order, and the 
dispatcher should be able to monitor a train's progress more closely because he would have 
current information concerning the locations and movements of all trains. Train crews 
would have positive meet arrangements and would have to obtain the dispatcher's 
authority to go beyond a specified operating limit. However, the safety involved in the 
TWC method of moving trains stiU depends on the train crews obeying the TWC authority 
and the operating rules. 

On April 6, 1984, the Safety Board investigated a train collision involving the TWC 
operation on the Atcheson, Topeka and Santa Fe Railroad at Castor, Texas. The TWC 
operation had become effective on February 1, 1984. The crew of an eastbound freight 
train had received a TWC to proceed to Castor and to clear the main track in the siding 
for a westbound freight train. The fireman, who was operating the train, became 
confused and thought that his train was to stay on the main track. (The engineer was in 
the engineroom checking on a problem.) The westbound train arrived at Castor first and 
as a result, since it was on the main track, the eastbound freight train collided head-on 
with the westbound train. One person was killed in the accident. 

As the April 6 accident indicates, the TWC authority is not a means to end all 
accidents. Moreover, the TWC most likely will impose a heavier workload on the train 
dispatcher, which could be dangerous. Therefore, all employees involved in train 
operations should be weU trained in the TWCs application and use. When the BN placed 
the General Code of Operating Rules and the TWC system into service on the Third 
Subdivision, an extensive rules training program was carried out. For several days after 
the April 27, 1986 implementation date, company officers and supervisors worked with the 
employees on the job to assist the operating employees, including the train dispatchers, to 
become familiar with the new rules. 



-28- 



Non-Critieal Elements 

Equipment. — Safety Board investigators examined and tested the non-derailed 
equipment of both trains. The brakes on the cars operated satisfactorily and the piston 
travel was within tolerance. Although it was not possible to conduct an operational test 
on the brakes of the locomotive units, no exceptions were taken to those controls and 
valves that could be examined. Based on the results of the inspections and tests, the 
Safety Board concluded that the brakes of each train were fully operable and would have 
stopped the trains if they had been applied in sufficient time. Also, the results of the 
calibration tests on the speed recorders of each locomotive indicate that the recorders 
were sufficiently accurate. Therefore, the engineers should not have had any difficulty 
adhering to the posted speed limits. 

Communications. — The locomotive radios could not be tested after the accident so 
it is only possible to analyze their performance on the reports concerning their operation. 
No adverse reports were made concerning the radio on Extra 6311 West so it must be 
assumed that the radio was operating satisfactorily. 

Since the engineer had complained about the performance of the radio on Extra 6575 
East at several different times, it must be assumed that it was operating less than 
satisfactorily on August 2. If the radio on unit 6575 had been operating properly, the 
engine crew might have overheard the transmissions made by the crew of Extra 6311 West 
while the train was at Clear Creek or MP 10. However, since frequency modulation (FM) 
depends on line of sight for optimum transmission and reception, it cannot be concluded 
that any or all transmissions from Extra 6311 West would have been received by Extra 
6575 East even with a high quality receiver. Uneven terrain or objects, such as buildings, 
could have blocked or deflected the FM radio signal so that it would never have reached 
Extra 6575 East. 

The Safety Board could not determine the effect of the radio system outage on the 
circumstances involving this accident. Since the engineer of a train normally cannot 
contact the dispatcher directly, it is questionable whether the engineer of either train 
would have gone through the routine of raising the dispatcher. If the radio system had 
been operable, even with a heavier work load, the dispatcher may have had the base 
station at Longmont "tuned in" and he might have stopped the movement of Extra 6311 
West before the accident. However, since there is no concrete evidence to support the 
effect the disrupted radio service might have had on the outcome of the accident, it 
cannot be concluded that the outage of the radio system had any bearing on the accident. 

The train dispatcher at McCook testified that even under the best atmospheric 
conditions, it was difficult for him to contact a train by radio in the Denver Yard or in the 
vicinity of Denver or to contact the operators at the 31st Street Yard. The problem in 
part is caused by the heavy usage of channel 1 in and around Denver and the distance 
between Denver and the location of the base station at Longmont, which serves the 
Denver area. The Longmont base station is apparently too far away to adequately serve 
the Denver area. Better coverage and improved communications might be achieved in the 
area if the point-to-point communications were routed through a repeater base station to 
increase the signal strength, if channel 2 could be used, or if the BN could obtain another 
channel to serve the Denver area. The lack of response to the emergency calls made by 
the conductor of Extra 6311 West probably was due to the conductor's radio signal not 
being heard in the Denver Yard area, which could have been the result of the transmission 
path, with incompatible terrain or obstacles to FM signals, or low receiver sensitivity. 
Additionally, when a radio transceiver is being used to transmit, the receiver will not 
simultaneously receive incoming signals. Also, if a transmitter has limited output power. 



-29- 



as in the case of hand portables, or if the output power has deteriorated, the range of the 
radio is limited, and it may not be transmitting a signal strong enough to activate a 
distant receiver. The optimum range of a portable radio is about 5 miles. No doubt many 
employees in the Denver Yard were using portable equipment and the distance between 
the conductor at MP 12.5 and the Denver Yard was too great for effective 
communications. The BN should strive to provide more reliable radio communications 
over its territory in the Denver area. When the TWC method of operation is implemented, 
the radio wiU become more important than it has been in the past. 

The Safety Board has long been interested in the application of radio use to railroad 
operations. Safety Recommendations have been issued to the FRA since 1976 addressing 
the need for radios to be required equipment on trains, the need for compatibility of 
radios between railroad properties, and the need for standards governing the use of radios 
in the industry. Recommendations also have been issued to various individual properties 
on the same issues. 

In its report of a train derailment at Essex Junction, Vermont, on July 7, 
1984, 14/the Safety Board cited the following statement made by the FRA Administrator 
at the National Transportation Safety Board's National Accident Investigation Symposium 
held in Washington, D.C., July 30-August 1, 1984. 

There were two things that I found imponderable before coming to FRA. 
One was the difficulty in reaching an agreement among all of the parties 
that would address in a fair way the alcohol and drug issue. 

The second imponderable was why we have been unable to develop a 
consistent program of radio communication in the railroad industry. 
Having addressed the first problem, we do intend to move to address the 
second, and we are going to begin proceedings that deal with the issue of 
communication, radio communication among railroad operating vehicles. 

The Safety Board stated, in part: 

[It] appreciates the concern expressed by the FRA Administrator over a 
year ago and urges the FRA to move swiftly in its efforts to address the 
use of radios and radio communication standards to improve operational 
safety in the railroad industry. 

To underscore its concern for this issue, on January 15, 1986, the Board 
recommended that the FRA: 

Establish regulations that address the issues surrounding the use of radios 
for operational purposes on trains to include, but not be limited to, 
requirements for radios to be installed on trains; usage requirements for 
inter- and intra-train communications; usage requirements for 
dispatching and control operations; frequency compatibility 
requirements; and maintenance, inspection, and testing requirements. 
(Class n, Priority Action) (R-85-129) 



14/ Railroad Accident Report— Derailment of Amtrak Passenger Train No. 60, The 
Montrealer, on the Central Vermont Railroad near Essex Junction, Vermont, July 7, 1984" 
NTSB/RAR-85/14). 



-30- 



On May 8, 1986, the FRA Administrator responded that: 

An examination of the industry's communication procedures and 
practices is a major element of FRA's safety agenda for this year. 

In the near future, I plan to initiate public hearings on the safety issues 
relating to railroad radio communications, including the central question 
of mandatory installation and use of radios. These hearings could well 
provide the basis for the development of an industry-wide set of 
technical and operational standards for radio communications or an FRA 
rulemaking should the data justify it. 

The Safety Board is pleased to learn of the FRA's intended action concerning radio 
communications, and it urges the FRA to expedite its efforts in this area. However, until 
such action is taken, the Safety Board reiterates Safety Recommendation R-85-129. 

Toxieologieal Tests 

The alcohol content found in the analysis of the blood sample taken from the 
engineer of Extra 6575 East resulted from microbial action. Because of the smoke and 
heat from the fire following the collision, immediate rescue efforts were delayed. After 
the rescue operations started and the bodies were recovered, some of the bodies were not 
removed from the accident site until late afternoon on August 3. Since it was a hot day, 
this exposure gave rise to the deterioration of the bodies. Therefore, the Safety Board 
concludes that alcohol or drugs were not involved in this accident. Also, based on the 
results of the analysis for carbonhemoglobin, the rear brakeman must have lived a short 
time following the collision. 

Sight Distance 

The conductor of Extra 6575 East testified that he saw the headlight of Extra 6311 
West as it emerged from beneath the highway bridge. Thus, it can be concluded that the. 
visibility was good. However, given the sharpness of the curve at MP 12.5 with the bridge 
structure and abutments located in the line of sight, the distance available for the 
locomotive crews to see each other was very limited. The maximum optimum sight 
distance established during the sight tests was about 870 feet, which probably was more 
than that available to the engine crews of the two trains because the bridge and the 
abutments had been removed at the time the sight tests were made. The only obstruction 
that remained at the time of the sight tests was the earth fills for the bridge approach. 
Therefore, the Safety Board could not determine the exact sight distance available to the 
crews of the freight trains, but it was insufficient to have enabled either train to have 
stopped once the other was sighted. 

Survival and Emei^eney Response 

The speed at which the two trains collided and the heavy load hauled by the gravel 
train would have caused an unsurvivable environment for those employees riding the 
locomotive of each train. In addition, the fire fed by the diesel fuel and lading from Extra 
6311 West, which made it impossible for rescue personnel to get to the wreckage, reduced 
the chances of survival. The Safety Board believes this accident was not survivable. 

Some emergency and rescue personnel rushed to the accident site when they saw the 
black smoke coming from the fire at the point of the accident. The emergency response 
by the emergency and rescue forces was timely and very effective. Even though the 
rescue forces were delayed in getting into the wreckage because of the fire, they were on 
hand and available when needed. 



Findings 



-31- 



CONCLUSIONS 



1. The operating rules and procedures had been followed properly by the 
dispatcher at McCook and the train order operators at Longmont and the 31st 
Street Yard. 

2. The crewmembers of each train had more than the required hours of rest 
between assignments, and fatigue should not have been a causal factor in the 
accident. 

3. There were no mechanical discrepancies in either train. 

4. Rail traffic was heavier than normal on August 2 for the 3 p.m. to 11 p.m. 
shift on the Third Subdivision because of the flood at Cheyenne on August 1, 
1985. 

5. Neither alcohol nor drugs were involved in this accident. 

6. Extra 6575 East exceeded the 100 tons per operative brake requirement and 
was thus limited to 30 mph. However, the speed tape indicated that the train 
was traveling about 48 mph at the time of the accident. 

7. In addition to the train order, the engineer of Extra 6311 West was given 
verbal instructions by the conductor to check the train register at Clear 
Creek. 

8. Since aU crewmembers of Extra 6311 West had passed the operating rules 
examination, each was qualified to check the train register at Clear Creek. 

9. One of the crewmembers on Extra 6311 West relayed to the other 
crewmembers erroneous information about the arrival of Extra 6575 East. 

10. It could not be determined conclusively which crewmember on the locomotive 
of Extra 6311 West checked the train register at Clear Creek since all three 
employees were qualified to do so. 

11. Locomotive unit 6575 had been used as the lead unit on the gravel train on 
August 1, 1985, and that entry into the train register could have been a factor 
in causing the crewmember to misread the train register information on 
August 2, 1985. 

12. There was no evidence of any medical factors being involved to have caused a 
misreading of the train register. 

13. Only limited radio communication facilities to and from the dispatcher were 
available on the Third Subdivision on August 2, 1985, and the quality of service 
and the coverage of the dispatcher's telephone circuit was limited and reliable 
only as far west as Longmont. 

14. Extra 6311 West and Extra 6575 East did not communicate with each other on 
August 2, 1985, and neither overheard any radio transmissions from the other. 



-32- 



15. The conductor of Extra 6311 West was unable to contact the operators at 31st 
Street Yard on BN radio channel 1. 

16. The speed recorders were sufficiently accurate so that the engineers of each 
train could have maintained the authorized speed within 2 to 5 mph with no 
difficulty insofar as keeping within the speed limits. 

17. In view of the high speed and heavy loads involved in this accident, the crash 
was not survivable. 

18. The emergency and rescue forces responded in a timely manner, but rescue 
efforts were impeded because of the fire following the collision. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of the 
accident was the failure of a crewmember of Extra 6311 West to read the train register 
information correctly at Clear Creek, Colorado, and the failure of the conductor to 
correlate that information with the train orders which caused Extra 6311 West to depart 
Clear Creek before the arrival of Extra 6575 East, a superior train. Contributing to the 
severity of the accident was the overspeed of Extra 6575 East. 

RECOMMENDATIONS 

As a result of its investigation of this accident, the National Transportation Safety 
Board made the following recommendations to the Burlington Northern Railroad: 

Implement, at intermediate train register locations, a backup procedure, 
such as telephone or radio verification of train arrivals, to provide train 
crews with a positive check on the status of other trains so long as the 
train register method is in operation. (Class H, Priority Action) (R-86- 
13) 

Require crewmembers who check train registers at intermediate 
locations to sign the train register and to provide the conductor and the 
engineer with the register information on the reverse side of the 
clearance card. (Class H, Priority Action) (R-86-14) 

Modify the radio system in use in the Denver area to provide reliable 
coverage in that area and to provide reliable and direct communications 
between mobile units and the train dispatcher at McCook. (Class H, 
Priority Action) (R-86-15) 

As a result of this investigation, the National Transportation Safety Board reiterates 
Safety Recommendation R-85-129 to the Federal Railroad Administration: 

Establish regulations that address the issues surrounding the use of radios 
for operational purposes on trains to include, but not be limited to, 
requirements for radios to be installed on trains; usage requirements for 
inter- and intra-train communications; usage requirements for 
dispatching and control operations; frequency compatibility 
requirements; and maintenance, inspection, and testing requirements. 



-33- 



BY THE NATIONAL TRANSPORTATION SAFETY BOARD 



/s/ PATRICIA A. GOLDMAN 
Acting Chairman 

/s/ JIM BURNETT 
Member 

Is/ JOHN K. LAUBER 
Member 

/s/ JOSEPH T. NALL 
Member 



June 20, 1986 



-35- 

APPENDIXES 

APPENDIX A 

INVESTIGATION 

The Washington Headquarters office of the National Transportation Safety Board 
was notified of this accident about 11:45 p.m. on August 2, 1985, by a Railroad Accident 
Investigator at the Safety Board's Denver Field Office. The investigator at the Denver 
Field office responded to the accident within minutes following the collision after he had 
been notified of the accident by a Broomfield, Colorado-Volunteer fireman. On August 3, 
1985, an investigating team was dispatched from the Headquarters office to Denver where 
they were joined by an investigator from the Los Angeles Field Office. Parties to the 
investigation were the Burlington Northern Railroad, the Federal Railroad Administration, 
the Colorado State Highway Patrol, the Colorado State Highway Department, and the 
Jefferson County Sheriff's Office. 

On October 30, 1985, a deposition proceeding was convened at Denver to take the 
sworn testimony of nine witnesses. Parties to the depositions were the Burlington 
Northern Railroad, the American Train Dispatcher's Association, the Brotherhood of 
Locomotive Engineers, the United Transportation Union, and the Colorado Public Utilities 
Commission. 



-36- 



APPENDIX B 
PERSONNEL INFORMATION 

Train Dispatcher 

Mr. James W. Hollis, about 35, had worked for the Chicago, Milwaukee St. Paul and 
Pacific Railroad Company as an extra operator and as a train dispatcher before he was 
employed by the BN as an extra train dispatcher in February 1976 at Alliance, Nebraska. 
On April 15, 1985, he was assigned to the 3 p.m. to 11 p.m. shift at McCook. 

TRAIN CREW EXTRA 6311 

Engineer 

Mr. J. Reeves, 58, had been employed by the former Colorado and Southern Railroad 
Company (C&S) as a fireman in September 1949. He was promoted to engineer in October 
1956. His service record indicates that he received disciplinary action in 1962 and 1964. 
In each instance, he operated a yard engine through and damaged a track switch, in the 
1964 instance causing the locomotive to derail. In 1970, he was dismissed once for his 
involvement in a collision and a second time for his failure to observe a reduced speed 
requirement which resulted in a derailment. In both instances, he was reinstated with his 
fuU seniority rights restored. On March 18, 1981, he was commended for promptly 
responding to a report that a car was derailed in his train and for bringing the train to a 
stop before any damage was done. 

Rear Brakeman 

Larry A. Baril, 46, was employed by the former C&S Railroad Company on 
March 28, 1960 as a switchman. On April 22, 1974, he received a dual promotion to the 
positions of brakeman and conductor. His service record indicates that he was censured in 
1963 and in 1964 for his involvement in sideswiping incidents. 

Head Brakeman 

Ronald E. Jordan, 37, was employed by the former C&S Railroad Company on 
August 20, 1979 as a student brakeman. He was promoted to brakeman on September 10, 
1979 and to conductor on October 2, 1980. He had no censures or disciplinary actions 
notated in his service record. He had completed one year of college. 

Conductor 

Howard L. Lynn, 58, was employed by the former C&S Railroad Company as a 
brakeman in 1957. He was promoted to freight conductor in 1961, and in 1966, he 
resigned from the C&S. He was re-employed by the C&S in January 1970 and he was 
promoted to conductor the same year. 



-37- 

APPENDK C 
TRAIN ORDERS EXTRA 6575 EAST 



CLEARANCE 






r •UDimCTDM 
HKMOMtON 



'' y, STATION (/ DATE 






TO: 



CleaiCnce 
No 



TO 



Ihav 


« / 


orders for your Train 




No. 


P7 














No. 


, 













No. 
















No. 















No. 















To be filled in when spacing trains 
Oo Not leave before M 



^/^ A. 



^y- 



r^^^^ 



CHIEF'-OISPATCHER 



OPERATOR 



FOR TIMESLIP INFORMATION ONLY 
YOUR COMPASS TRAIN NO: 



(This number must appear on your timeslip) 



FORM 15216 8-79 



(OVER) 



APPENDIX C 



-38- 



TRAiN ORDER Wo 22. 



BURUNCrOH 

NORTNERK 

4UKJKM0 



LOCATION 

LONnMn^^■ 


OATE 

ADH 2 19B5 


^° C*E E^TPA 657*^ VF*^T ^T ^-l F^R rRFFK 


TO ^ipp pp HAF FXTRA 6575 CAST 


TO 


TO 


TO 



EXTRA 6575 WEST HAS RIGHT OVER EXTRA 8060 EAST 
AND EXTRA 8160 EAST CLEAR CREEK TO LONGMONT 
EXTRA 6575 WEST REGISTER AT LONGMONT 
ON ORDER NO 27 OF AUG 2 
EXTRA 6060 EAST AND EXTRA 8160 EAST 
MAY CHECK REGISTER AT LONGMONT 

AGAINST EXTRA 6575 WEST ON ORDER NO 27 OF AUG 2 

JWH 



TIME COMPt-ETEO 



FOBM 15108 l-«Z BEAD ALL 



\LL TRAIN O^enS PROt* 



OPERATOR 




u 



PROMPTL Y--brSCt/SS7VNDERSTAND ANO COUPL Y WITH THEM 



-39- 



APPENDIX C 



CLEARANCE ^^ ra^ST 



^^^STATION 



TO:Ca. 



)n" ^^^ DATE 



19 



/"^ 



Clearance 
No. 



TO 



orders for your Train 



--o..^?/ 


<1^^^7 


^/ 


39 


¥^ 




No. 




No. 


1 


No. 






No. 











To be filled in when spacing trains 
Do Not leave before M 



TIME OK-D 



^/¥ /<. 



^W^ 



CHIEF*DISPATCHER 



OPERATOR 



^X^>^ 



FOR TIMESUP INFORMATION ONLY 
YOUR COMPASS TRAIN NO: 



(This number must appear on your timeslip) 



FORM 1B215 8-70 



(OVER) 



APPENDIX C -40- 



TKAIN, ORDERS -. 



It?l RAILROAD TK'ACK WARRANT CONTROL RESTRICTED TRACK CONDITIONS 



RTC NO 631 ■ . AUG <;1985 



TO: C&L" WESTWARD TRAINS AT 31ST ST YARD 
e^E-EASWARD-Tf'A-I^x'S — — ATH:-KE-¥€t^N&- 



C&E TRAINS ORIG - - AT FT COLLINS 
-C^E-T4?A I NS-ORIG- . . ^ A-T-tONGiiaN=r— 



FROM 6G1 AM UNTIL 601 PM MONDAY THROUGH FRIDAY DO NOT EXCEED 

^P- ,t!F:^i::?ETUEEN HP 9 AND KP iO BETWEEN CLEAR CREEK Af:JD BROOMFIELD 

FREELY WITHIN THESE LIMITS 

OUTBOUND ^5T BETWEEN KP 2.5 AND MP 3.4 BETWEEN JERSEY CUT OFF AND 
^JT^H--JC-T-HASHBEENH?EM0VED-4.'0RMAbH^Si:^-MN-f«R-SWIi^t-^T-48T1^-^ 

ON OUTBOUND IS LINED AND LOCKED FOR CROSSOVER NORMAL POSITION FOR 
-SWI-T-G+:H3K-I-^>IBBUi\'D-IS-tiNE&-ANI>-tGEK-Ei)-F0R-I-NBGUKD- '■ ■■ : 



-^T-*R00MF4E4H)-OGG4JP-IED-0UTF^^F-eAR5H3f>h-H0USE-Ti^ACK-MUS-1h-tlOT-BE- 
COUPLED INTO OR MOVED 



LOOK OUT FOR TIES AND TRACK MATERIAL ALONG MT^AND SIDINGS BETWEEN 
-BROOHFIELrD-AND-NORF^Id< ' : ^ '■ 



H^T-L<)NGMQNT-fHJR"E-GAS-SfHJRH3UT-<)r-^£'RVi-eE-200-FEE-T-WE5T^ — 

AT LONGMONT IN EAST YARD BROKEN RAIL 4 CAR LENGTHS EAST OF WEST SWITCH OF 
-t<10 -2-q RACK ~ — : — ■ ^— . ; — 

-AT-^ERTfieUD-^H^I-{>!G-BtQeK€-i>-WHH^-eHR5 — — — — -— ^T — — ...... 



-AT-GAMP€^f^|-+^0USE^^RACK-^3U^MDF-5EfWi€i^-AND--Stm^^H-SPi1< 

H^T•^;0VEtrAND-H0US£-T^•^AeK--OUT-€F^5€^=;■Vi-eE-SWIT^^^-i•S--^F^fK€l)-T^ — — ^ 
GW INTERCHANGE TRACK OUT OF SERVICE SWITCHES SPIKED 

-AND-&l4--44^469-0NHiWHrR4^N5FH=f:--liUS'F-N6T-BE-M0VED-inR-eebPl^^ 

....... . ■ , V . ■ _ . 

-^f-fl9RFObK-W0USE-T^^AeK-OUT-H3F^€f<VKE-AND--SiJlVeHE^ARE-^ 
AND SPIKED FOR SIDING , .• i. , 

. '■■ . ■'■■ : '<■- ■ ■ - '■ • '■■ '' ■' ^-- ' - '"■ 



look: OUT FOR SCRAP AND TRACK MATERIAL BETWEEN MP 119.35 AND 
^■JF^-4-1-»x-5-&ET-WEEf4-SP&ERH=>MD-FE-DER^ L " : :.. . ,. : . . -^ 



^T-CHEYEji<NE— RGGK-^RAGK-QUT^F-SERVieE- 

;. ' . .'■ ■ JWH 



"^^ 



Z^^ 



-41- APPENDIX C 



X01 P39 F'39.203742ElOG3 _ 

O.t.H. l<14lf8G **i VIA CeC? - FILE (?(? «* 

I<i4n80 00201618 08/02/85 U320 

niHiiiK^SK' ZZ' Q\'2072A Gi2072A JUH" N456 ZZ 



h\i RAILROAD TRACK WARRANT CONTROL RE-S-TRICTED TRACK CONDITIONS 

~~AUG 2~1985 



RTC NO 635 




Ci,E: UEIS-TUARD TRAINS" 


AT 


C&E EA.^TUARD TRAINS 


AT 


C&E TRAINS ORIG 


AT 


CAEJIRAINS. ORIG 


AT 


IT EXCEED 





TO: Ci,E UESTUARD TRAINS AT 31 ST STREET YARD 

£HEYENNE. ^ 



FT COLLINS 
. LONGMQNT_-_- 



10 MPH BETWEEN HP J 6.J_ AND_ JIP 1JL H^E:TUEEJlJ(ROO^iFIEL£-AND_BI)ULI'tK..- 
tRACK FLAGS NOT DISPLAYED 

10 MPH BETWEEN MP 44 AND MP 45 BETWEEN LONGMONT AND HIGHLAND 

;- ;.c:: . JUH 



5o9^^ 



APPENDIX C 



-42- 



TRAIN ORDER No. 



28 



LOCATION 

LONOMONT 


DATE 

AUG 2 iJ85 


TO C8£ EXTRA 6575 EAST 


TO 


TO 


TO 


TO 



EXTRA 6575 EAST HAS RIGHT OVER EXTRA €311 VEST 
LtNGMONfT TO CLEAR CREEK 

EXTRA 6575 EAST REGISTER AT CLEAR CREEK 
ON ORDER NO 28 OF AUG 2 

EXTRA 6311 WEST MAY CHECK REGISTER AT CLEAR CREEK 
AGAINST EXTRA 6575 EAST ON ORDER NO 28 OF AUG 2 

JWH 



TIME COM Pt.ETED 



FORM 16108 l-«2 ff^^p 



ALLTRAINORDERS PHOMI 




PftOMPTLY- DISCUSS. UNDERSTAND ANO COMPLY WITH THEM 



-43- 

TRAW order No. ss 




APPENDIX C 

"^^^^P BORUNGTTJW- 
^^^^n NORTHERN 

mm^tm luuLROAn 


IjOCATION 

tONGMONT 


DATE 

AUG 2 i985 


"^0 rUF FVTRA fiS7S TA^T 


to 


TO 


TO 


TO 



EXTRA 6575 EAST HAS RIGHT OVER EXTRA 7036 WEST 
LONGMONT TO CLEAR CREEK 

EXTRA 7036 WEST MAY CHECK REGISTER AT CLEAR CREEK 
AGAINST EXTRA' 6575 EAST ON ORDER NO 28 OF AUG 2 

JWH 



TIME COMPl-ETEO 



.^ 



FOftMJSloa l-*i BEAD ALL THAIN 



. ^42 

mOH^nSPHOtAPTLY- DtS&JSS. UNDERSTAND AND CXWPL Y 



WITH THEM 



APPENDIX C 



-44- 



TfiAtN SRDER No. 



44 



"^"^""^ LONCMONT 


DATE 


AUG 2 ^985 


TO ic&E ENQ 6575 


TO 


TO 






TO 


TO 



ENG 6575 RUN EXTRA LONGMONT TO CLEAR CREEK 

AND RETURN TO LONGMONT 
JWH 




)S>BM 15X08 l-*2 psadALL TKAifN OROenS promptly- discuss. UNOeRSTANOANOCCMPLYWITH TH£M 



-45- 



APPENDK D 
TRAIN ORDERS EXTRA 6311 WEST 



CLEARANCE 



<-?A/.^ 



or 3e c (, 

^BURUNGTON 
WWTMERN 
RAUtOAD 




( ^i ^ o? 19 i&: 






Clearance 
No. 



7- 



orders for your Train 



* u/ CSS a^ ^s '^ yc 




NO. ^7 




No. 



No. 
















No. 















To be filled in when spacing trains 
Do Not leave before M 






= mSPATCHER OPERATOR 



CHIEF DISPATCHER 



FOR TIMESLIP INFORMATION ONLY 
YOUR COMPASS TRAIN NO: 



(This number must appear on your timeslip) 






FORM 15215 8-79 



(OVER) 



APPENDIX D -46- 



o.jJh; k^20977'''i*^ via ce& - file gb *« 

k22pg7J'6020 '1700 08/01/85 U294 
f tJtTAS'K'-2Z-Ci^0724— G12«7^24— -J< 



C12«7^24— -JWH-N390 Z2 

■J ',:■■■• 



^ROAB-TRAeK-WAR^^ANT CnNTROI.— REi?Tf<-irTEI) -TRA0K-e fJNl)IT1 GN.-? 
— RTC NO-631 _-.AU(i-i -1985- 
-^M)-:— C^,^■ WESTWARD TFv-AINS AT Ti^lST .^T YARD 

C&E EASTWARD TRAINS AT CHEYENNI-: 
C4,E— Tfs-AINS- DRIC AT- FT-COI .1 . T HS 



CiE TRAINS ORIG AT LONGHONT 



FROH 601 AM UNTIL. 601 PM MONDAY THROUGH FRIDAY DO NOT EXCFFD 
i^-WF^H -BETWEEN MF^-9-ANB-MP-10-*ETWEEI^ CLEAR-GF: r. CI ( AMD r i ROO H FIELD 



DUE TO MEN AND EQUIPMENT CROSSING OVER MT SOUND BELL AND WHISTLE 
FREELY W ITH LN— TH ESE LIMITS 

^OUTBO U N D MT BET WEEN MP 2.5 A NI>-41P-3^-4-BE-TWE EN JE R SEY CUT Off Mt'^'^'^^Hl 
:UTAH JCT HAS BEEN REMOVED NORMAL POSITION FOR SWITCH AT 48tK"'AVEStl/^^^* 
U) M "" OOTBOUMD I y "L IMEP A ND"' LQ GKH>-R3R CROSS OVEt^KQ RM aL' POSI 1 1 ON roir^^T:";^ 
/"SWITCH ON INBOUND IS LINED AND LOCKED FOR INBOUND ._ ■ •---?•> 'f-----*^^?? 

AT BROOMFIELD OCCUPIED OUTFIT CARS ON HOUSE TRACK MUST NOT BE 
-COUFiLEJUINTO-OR-^OVED 



-LOOK O U T FQR-XI£SL-AND-TRACK-^ATERIAL- ALONG MT-AND SIDINGS BETWEEN — ^ 

BROOMFIELD AND NORFOLK 

AT LONGMONT PURE GAS SPUR OUT OF SERVICE 20G FEET WEST OF SWITCH 

A T LQ NGMONT I N EA^^T^YARD-^RQKEN-RATL-^-GAR-LENGTti S EAST OF WEST SWITC H OP 

NO 2 TRACK 



AT BERTHOUD SIDING BLOCKED WITH CARS 



AT CAMPION HOUSE TRACK OUT OF SERVICE AND SWITCH SPIKED 



AT LOVELAND HOUSE TRACK OUT OF SERVICE SWITCH IS SPIKED 
.Gl.^-INT£RGHANGF=-T^ ACK-OUl— OF- SER V I C-&-^ I-TGH&S-^F-^-EB- 



AND BN 410469 ON GW TRANSFER MUST NOT BE MOVED OR COUPLED INTO 

AT NORFOLK HOUSE TRACK OUT OF SERVICE AND SWITCHES ARE LINED 
^NIX-^SR44C£»-FOR-SiDiWG 

LOO K O UT FOR SCRAP A ND T RACK-MAT ERI A L BET WEEN MP \ \ 9 .35 AND 

MP 119.5 BETWEEN SPEER AND FEDERAL 

AT CHEYENNE ROCK TRACK OUT OF SERVICE 

dWH- 



G_tLlfl2l 




-47- APPENDIX D 






20 977 "*» VI A C e G-^^F~ I L^-e (? -* it 



'K2209i7V0020 fl618 08/G2/85 U065 

1#V?¥TAVK 77 r.t2a724 — C4-2a724 lUH - HA56-JIZ~ 



M 



i^iJV; 



, BN RATI ROAH -TRACK UARRANT CONTROL RESTR I CTEl) - T RACK-OO NI) I T U mS- 



RTC NO-i.35- AU(; 2 198 ^. 



:d.£_UESIUARD- TRAINS. AT SU^X^STT-i EET YA RJD- 

C&E EASTWARD TRAINS AT CHEYENNE 

C&E TRAINSL-ORJC AT F T COLLI NS 



■ C&E TRAINS ORIG AT LONGMONT 



DO NOT EXCEED 



10 MPH BETWEEN MP 16.5 AND MP 17 KETUEEN BROOMFIELD AND BOULDEg^,;****;*.***.-* 

TRAn k-Ft Ar.v NhT DTSPi AYFD — _ _: — : -1:1- : — — :V;' — -_. , '. 






APPENDIX D -48- 



)<0!] P06 PG6 585934BG03 
i).I.H._K2i0922 ** VTA rPP) - FTl F nii uv 

K220977 0020 1656 ©8/02/85 U088 
-**f*t«jrASK -ZZ.-G1_2©724 G 120224 -^JIJH^J^472 -Z2. 



JBN RAILROAD-TRACK-UARRANJ-XONT-fiOL-RE^TRJCIflD -TRAUK-COfiUlilGNi'- 
.., RTC_N0^36 AUG_2- 1-985- 

_TD.;. - _£i£_UEi:iiJARD._TJl:AI MS AI 3Jj;T_SJ:REE.T_i'i^RJ) _ 

C^F EA5-TUARD TRAINS' AT CHEYENNE 

C&E JJES'TUARD.J-JCAINS ■ Al XHEYENNE 

C&E TRAIN;? ORIG AT WHEATLAND 

Ci.E_EA5TUARD-XRAIN5 AT '-GUERNSEY 



AT CHEYENNE FOl.LOUING TRACKAGE OUT OF SERVICE DUE TO WASHOUTS 
..WEST LEG_DF ^WYE . 

TETON LUMBER 
-.CHEYENNE -BEVERAGE 

MISSLE SWITCH 
.JRDiJNDhlOUS£_LEAD-.__-_ 

6 TRACK 
_-5_.TRACK 



4 TRACK AND MT IN SERVICE 



AT CHEYENNE WATCH OUT FOR UNEVEN FOOTING AND TRIPPING HAZARDS 

-DUF TH-HJ GU_WA1£R 

JWH 



-^-^d)^^^?'^- 



-49- 



APPENDIX D 



IRMN ORDER UO.^I ^^ 



BURUNGTON 
NORTHERN 



DATE 



AUG 2 .IS6} 



TIME 



I «-<^-'y'ON 31ST STYARD 



i TO 



XX£ JEXIRA_£3-U JfEST _ 



TO 



EXTRA 6575 EAST MAS RIGHT OVER EXTRA 6311 WEST LONGMONT 
TO CLEAR CREEK 

EXTRA 6575 EAST REGISTER AT CLEAR CREEK ON ORDER NO 28 
OF AUG 2 

EXTRA 6311 WEST MAY CHECK REGISTER AT CLEAR CREEK AGAINST EXTR^ 
^575 EAST ON ORDER NO 28 OF AUG 2 

JWH 



IrTIMUSCOMntTED 



505 ^M 



ETTLE 



rcwM JsiOP 17^ ^f^P jf;^l,; f);?,f>r.'.:. I ROM! 11 \ [■r.ri-- :., UHUtfi^iUND AND CO/Arl) K^IIH V ? 



APPENDIX D 



-50- 



JRAIN ORDER UQ. 



«*5 



' L0CA7I0N' 51 St .St ^tard 



^F^^ 


'''' AUG 2 1985 ■ ■ 


^^ss^ 


TiNiL ; 


BUnUNGTON 
NORTHERN 



i TO 



! TO 



C«E EXTRA 6311 WEST 



TO 



TO 



TO 



^ 



EXTRA 6311 WEST TAKE SIDING MEET 

EXTRA 8060 CAST AT NORTH YARD 

JWH 



I'TIMt ,CC-M»LF.TCU 



619 f»M 



1 opi iv--.;cR 



ETTLE 



fOB^TUioE J 76 , f^^^Q TRAIN ofeDERs pRo^A^ly nizcuss. understand and compv. with them 



-51- 



APPENDIX D 



T£/IIRS ORDER KO. 



MS 



eURLINGTOK 
NORTHERN 



DATt 



AUG 2 198S 

or; p. 



UMC 



i LCCATirJN 5 1ST ST YARD 



10 



C6E EXTRA 6311 WEST 



TO 



EXTRA 6311 WEST TAKE SIDING MEET 
EXTRA 8160 EAST AT NORTH YARD 

JWH 



T;r^f. CON-.! 1 fTLC 



622 PM 



r: r../toh 



ETTLE 



*CKM isjoB 176 jjg^p VAIN OPr'.FS rKo.'.'.rr/v - c;';c,lss, u/«/n£Rsr/irvo ano cowpi. v./th them 



APPENDIX D 



-52- 



IPA1S ORDER UO. 



h7 



BURUNGTCN 
NORTHEP.r 



AUG 2 1985 



TI(.T. 

i 



LOCAT.ON 3 1ST ST YARD 



TO 



' 10 



C8E ENG 6311 



TO 



: TO 



ENG 6311 RUN EXTRA UTAH JCT TO CHEYENNE 



\'-]"t'.:.Ccot-'.r\r(io 



fciSt 15) 



62^ PM 



ETTLE 



fOt-'V! 15)0K 1 76 ^^f, 



7f A.'N c7'"t.<s rRO.wnY - r.-.r yss. uNi>z^su.y-o and coaipiv w/rH i^^ '"^ 



-53- 



APPENDIX E 



REVERSE STOE OF CLEARANCE CARD USED FOR 
TRAIN REGISTER INFORMATION 



TRAIN REGISTER CHECK 



Tlm^ M. Dnt* 19 


TRAIN 


TIME 


Signals Registered 


Arrived 


Departed 



















































































































































Conductor 



PRINTED IN U.S.A. 



-54- 



APPENDIX F 
TRACK WARRANT CONTROL AUTHORITY 

TRACK WARRANT CONTROL AUTHORITY 

TRACK WARRANT NO. _____^_ , 19_ 

TO: AT: 



(1) □ TRACK WARRANT NO. IS VOID. 

THIS »S AUTHORin TO: 

(2) □ PROCEED ONLY AS AUTHORIZED BY CTC SIGNAL INDICATION, or Train order 

(3) □ PROCEED FROM TO 

(4) □ WORK BETWEEN AND 

SUBJECT TO THE FOLLOWING SPECIFIC INSTRUCTIONS: 

(5) □ NOT IN -EFFECT UNTIL AFTER ARRIVAL OF 

— AT 



(6) n NOT IN EFFECT UNTIL AFTER DEPARTURE OF 
— AT 



(7) □ NOT IN EFFECT UNTIL ^H. 

(8) □ PROTECTION AS PRESCRIBED BY RULE 99 NOT REQUIRED. 

(9) □ CLEAR MAIN TRACK AT LAST NAMED POINT. 

(10) □ HOLD MAIN TRACK AT LAST NAMED POINT. 

(11) □ BETWEEN AND ^^_ 

— MAKE ALL HOVEHENTS AT RESTRICTED SPEED AND STOP SHORT OF HEN OR 

MACHINES FOULING TRACK. 

(12) n BETWEEN AND 

MAKE ALL MOVEMENTS AT RESTRICTED SPEED. LIMITS ARE OCCUPIED BY MORE 
THAN ONE TRAIN OR ENGINE. 

(13) □ AUTHORITY EXPIRES AT ^M. 

(14) □ DO NOT EXCEED 

MPH BETWEEN AND 

MPH BETWEEN AND 



(IS) □ OTHER SPECIFIC INSTRUCTIONS _ 
Obtain oloaranoe at M 



RTC(s) NO. NO. NO. NO. NO. 

OK'd AT M. DISPATCHER 



RELAYED BY COPIED BY 



REPORTED CLEAR AT M. BY 

(Mark 'X" In box for each applicable Item.) 



4-64 



>U.S. GOVERNmENT PRINTING OFT ICE : 1986- A91 -098 :4(1032 



NATIONAL EMERGENCY 

TRAINING CENTER 

LEARNING RESOURCE CENTER 

16825 SOUTH SETON AVENUE 

EMMITSBURG, MD 21727 

NETC LRC 



002278 



i J 3 O 
a a a m 






£ o 

S 

<n m 



M-*a 


O 


a8(M:q 


lO 


300 t-a 


.mt 


HMO 


o 


>4U1 


o 


W tr^ 


UJ 


COWM 




aooo 




wa» 




OHI»» 




ails 




H 




M 




H 




•4 




O 




SB 




CS 




03> 




< 




tow 


XI 


-*s 


CB 


04CI 


er 


NJttl 


n; 





-0 




O 


TD 


W 


CB 


H 




>CD 


3 


oc 


z 




o 


m> 


O 


ro 


com 


CD 




fO 


"□ 




> 




o